Errors and near misses in digestive endoscopy units.

Area of Science:

• Gastroenterology
• Patient Safety
• Healthcare Quality Improvement

Background:

• Limited understanding of errors and near misses in digestive endoscopy procedures.
• Need for systematic data collection on unintended events in endoscopy.

Purpose of the Study:

• To assess the utility of incident reporting, enhanced with specific features, for capturing unintended events in digestive endoscopy.
• To gather data on errors and near misses, excluding diagnostic medical errors.

Main Methods:

• Prospective, multicenter study across nine endoscopy units over two weeks.
• Staff reported unintended, potentially dangerous events using forms with reminders and facilitator support.
• Data collected included event type, causes, interventions, workflow stage, and reporter qualifications.

Main Results:

• 230 relevant events reported, representing 10.3% of procedures.
• 71% of events were near misses (164), and 29% were errors with consequences (66).
• Most errors occurred pre-operatively (65%), with nurses being primary reporters (46%).

Conclusions:

• Short-term incident reporting, emphasizing near misses and utilizing facilitated reporting tools, yields valuable insights.
• This approach can significantly improve the understanding and management of errors in digestive endoscopy.
• Facilitated incident reporting is a viable strategy for enhancing patient safety in endoscopic settings.